HDL-Boosting Combination Therapy Complexes

ABSTRACT

A pharmaceutical composition including therapeutically effective amounts of at least one HMG-CoA reductase inhibitor present as a dyhydroxyacid salt and at least one additional therapeutic agent.

RELATED APPLICATIONS

This application claims priority to U.S. application Ser. No.10/983,836, filed Nov. 8, 2004, which claims priority from U.S.Provisional Patent Application No. 60/518,091 filed Nov. 7, 2003. Thepresent invention relates to the use of water-soluble salts of dihydroxyopen acid statins that are inhibitors of3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase in combinationwith at least one additional therapeutic agent.

BACKGROUND

Various medical conditions, including but not limited to certain formsof cancer, hepatic malfunctions, dementias such as Alzheimer's disease,and various lipid abnormalities can be advantageously treated usinginhibitors of HMG-CoA reductase. It is also posited that various otherdiseases and medical conditions are related to pathways that utilizeHMG-CoA reductase. Thus treatment regimens utilizing HMG-CoA reductaseinhibitors are valuable and warranted.

In many instances, combination therapies employing two or moretherapeutic compounds are required to adequately address the medicalcondition and/or physical effects secondary to the condition undertreatment. Thus, HMG-CoA reductase inhibitors can be employed withvarious other therapeutic agents to address lipid abnormalities.Combining two lipid-lowering medications safely and effectively improvesoverall beneficial effect on all lipid abnormalities and reducesmultiple coronary heart disease risk factors.

Coronary heart disease (CHD) is currently managed by various drugtherapies that include HMG-CoA reductase inhibitors (collectively knownas statins), as well as other compounds such as fibrates, bile acidsequestrants, niacin and the like. Of these drugs, statins are the mostprescribed because they are effective in lowering total cholesterol andlow-density lipoprotein cholesterol (LDL-C). It has been found thatstatins have a small to moderate effect on triglycerides and a minimaleffect at raising high-density lipoprotein cholesterol (HDL-C) levels,the so-called “good cholesterol”. While the National CholesterolEducation Program (NCEP) treatment guidelines recognize LDL-C as theprimary target of therapy for prevention, it now focuses on HDL-C levelsas a major risk factor. Moreover, the Adult Treatment Panel (ATP) ofNCEP has now raised the HDL-C lower limit from 35 mg/dL to 40 mg/dL.

Statins are not effective at increasing HDL-C. However, various othermaterials such as fibrates can increase the level of HDL-C “goodcholesterol.” Combined statin and fibrate therapy is often imperativefor the improvement of the serum lipid profile in patients with mixedhyperlipidemia. However, the potential risk of myopathy has limited thewidespread use of such therapy. Current combination therapies recommendseparate dosing to minimize peak dose interactions. Thus, dosingregimens can include weekly administration of a material such as afibrate together with daily statin treatment. Other treatment regimensmay include a fibrate prescribed in the morning and a statin prescribedat night to minimize peak dose interactions. Such dosing complexity canlead to compliance problems and less than desirable dose response in apatient.

Thus, it would be desirable to develop formulations of water-solublesalts of statin dihydroxy open acid and other suitable components havingsuitable effect on cholesterol, triglyceride, or related bloodchemistries. It would also be desirable to provide a formulation of suchmaterials in a single pill or dose form in order to address the overalllipid abnormalities. It would also be desirable to provide a dose formin which the water-soluble statin dihydroxy acid salt and other lipidaddressing materials are present in a form that would enable formulationof a combination drug that can be administered at therapeuticallyeffective low doses in order to eliminate undesirable side effects.

Similar dosing complexities exist in treating other medical conditionsfor which HMG-CoA reductase inhibitors can be utilized. Thus, it wouldbe desirable to provide therapeutic compositions that combine HMG-CoAreductase inhibitors and other complementary agents in a single doseform for treating various illnesses and conditions that are moderated orcontrolled by HMG-CoA reductase.

SUMMARY

Disclosed herein is a therapeutically effective formulation involving acombination of an HMG CoA reductase inhibitor and at least one othertherapeutic agent. The combined formulation is designed to improve theoverall beneficial effect on all lipid parameters. The combinedformulary can consist of a water soluble salt of a dihydroxy open acidstatin and a water soluble salt of a fibrate.

DETAILED DESCRIPTION OF THE EMBODIMENTS

Currently used therapeutic agents addressing lipid abnormalities,particularly those occurring in coronary heart disease include, HMG Co-Areductase inhibitors. Other therapeutic agents addressing lipidabnormalities include, but are not limited to, fibrates, bile acidsequestrants, and niacin. Each of these materials is typicallyadministered as monotherapies in which multiple materials areindependently administered to address various lipid abnormalities.Disclosed herein is a pharmaceutical formulation in which at least twotherapeutically effective entities are combined and can have the effectof reducing factors such as total cholesterol, LDL-C, triglycerides,and/or at increasing levels of HDL-C, popularly known as “goodcholesterol”.

In addition to use as therapeutic agents addressing lipid abnormalities,HMG-CoA reductase inhibitors have demonstrated efficacy in the treatmentof certain forms of cancer as well as the potential for addressingsymptoms of Alzheimer's disease.

Disclosed herein is a therapeutic combination that contains at least onetherapeutically active form of an HMG CoA reductase inhibitor and atleast one additional therapeutic agent that is a compound other than anHMG CoA reductase inhibitor. The additional therapeutic agent may becapable of addressing at least one lipid abnormality.

As defined herein, the term “lipid abnormality” is taken to mean adeviation in at least one of total cholesterol value, LDL-C,triglyceride, or HDL-C levels from that defined as normal or acceptableby the National Cholesterol Education Program. The currently acceptednormal values are listed in Table I. It is understood that the materialsutilized in the therapeutic combination are those that address at leastone of the lipid abnormalities in a statistically acceptable number ofindividuals. Thus, the materials utilized in the therapeutic compositiondisclosed herein will address at least one of total cholesterol, HDL-C,LDL-C, and triglycerides. It is contemplated that the materials mayaddress more than one of the aforementioned abnormalities as desired orrequired.

TABLE 1 Normal Serum Values (mg/dL) for Various Lipoprotein Materials asDefined by National Cholesterol Education Program TOTAL RATING CATEGORYLDL CHOL HDL CHOL TRIGLYCERIDES CHOLESTEROL Optimum <100 >60 <100 — NearOptimum 100-129 50-59 100-149 <200 Increased Risk 130-159 41-49 150-199200-239 High Risk 160-189 35-40 200-399 >240 Very High Risk >190<35 >400 —

It is contemplated that “addressing at least one lipid abnormality” willbe evidenced by a positive trending resolution toward the desired valueas defined by appropriate agencies and individuals. It is to beunderstood that the material of choice may exhibit effect on lipid andlipid-like materials even within the range defined as acceptable by theappropriate agency or individual and/or that defined in Table I.

It is contemplated a therapeutic agent capable of addressing at leastone lipid abnormality can include at least one of peroxisomeproliferator-activated receptor agonists, cholesterol ester transferprotein modifiers, either as inhibitor or agonist, long-chain carboxylicacids, long chain carboxylic ether compounds, and the like. Examples ofsuch materials can include but are not limited to water solublematerials such as fibrates, niacin and insoluble or semisolublematerials such as bile acid sequestrants.

It is contemplated that the therapeutic agent is used in combinationwith a suitable HMG CoA reductase inhibitor. The HMG CoA reductaseinhibitor in the composition can be present as its biologically activeform.

The term “HMG CoA reductase inhibitor” as used herein is intended toinclude inhibitors of the 3-hydroxy-3-methylglutaryl co-enzyme Areductase pathways. In particular these include statins: a structuralclass of compounds that contains a moiety that can exist either as a3-hydroxy lactone ring, or as the corresponding dihydroxy open acids.

All hydrates, solvates, and polymorphic crystalline forms of HMG-CoAreductase inhibitors having the above-described dihydroxy open moietyare included within the scope of the term “statin”. Pharmaceuticallyacceptable salts and esters of the dihydroxy open acid statins areincluded within this term.

Statins inhibit HMG-CoA reductase in the dihydroxy open acid form.Compounds that have inhibitory activity for HMG-CoA reductase can bereadily identified using assays well known in the art. Examples of suchassays are described or cited in U.S. Pat. No. 4,231,938 at column 6. Asdisclosed herein, the HMG-CoA reductase inhibitor can advantageously bea dihydroxy open acid statin.

The term “dihydroxy open acid statin(s)” is intended to be defined asstatins containing the dihydroxy open acid moiety includingpharmaceutically acceptable salts and esters thereof. The phrases“dihydroxy open acid statin(s),” and “dihydroxy open statin(s),” and“pharmaceutically acceptable salts and esters thereof” are usedinterchangeably herein and are all intended to encompass the open acidand salt and ester forms of the open acid of the statin, unlessotherwise indicated. All hydrates, solvates, and polymorphic crystallineforms are encompassed within the scope of the term “dihydroxy open acidstatin(s).” In the broadest sense, any dihydroxy open acid statin or apharmaceutically acceptable salt or ester thereof may be used in thepresent invention. The HMG CoA reductase inhibitor can be one derivedfrom the lactone form having the general formula:

in which R is the statin chromophore of the respective compound. The HMGCoA reductase inhibitor compound employed herein is present as itsbiologically active form having the general formula:

in which R is the statin chromophore for the respective compound.Non-limiting examples of statin chromophores include at least one ofsimvastatin, lovastatin, pravastatin, fluvastatin, atorvastatin,cerivastatin, pitavastatin, and rosuvastatin. The materials of choicegenerally exhibit water solubility.

As used herein “water solubility” is defined as the ability of at leasta portion of the material to dissolve or be solubilized by water. Thus,examples of dihydroxy open acid statins that may be used with thepresent invention include, but are not limited to, dihydroxy open acidforms and pharmaceutically acceptable salts and esters of materials suchas: lovastatin, simvastatin, pravastatin, fluvastatin, atorvastatin,cerivastatin, pitavastatin, rosuvastatin.

In the broadest sense, pharmaceutically acceptable salts of statindihydroxy-acid include, but are not limited to, cation salts such assodium, potassium, aluminum, calcium, lithium, magnesium, zinc, andtetramethylammonium, as well as those salts formed from amines suchammonia, ethylene diamine, n-methylglucamine, lysine, arginine,ornithine, choline, N—N′ dibenzylethylenediamine, chloroprocaine,diethanolamine, procaine, N-benzylphenethylamine, 1-p chlorobenzyl-2pyrrolidine-1′-yl-methylbenzimidazole, diethylamine, piperazine,morpholine, 2,4,4-trimethyl-2 pentamine, andtris(hydroxylmethyl)aminomethane, as well as pharmaceutically acceptableesters to include, but not be limited to, C₁₋₄ alkyl and C₁₋₄ alkylsubstituted with phenyl, dimethylamino, and acetylamino. As used herein,the term “C₁₋₄alkyl” includes straight or branched aliphatic chainscontaining from one to four carbon atoms. Nonlimiting examples includestraight or branched aliphatic chains such as, methyl, ethyl, n-propyl,n-butyl, iso-propyl, sec-butyl and tert-butyl.

It is contemplated that the dihydroxy open acid statin will beformulated for oral administration in a manner that allows for deliveryof the dihydroxy open acid statin without its lactone counterpart. Asdesired or required, the dihydroxy open acid statin can be formulated tobe delivered directly to the absorptive mucosa of the small intestine,thus allowing for absorption of the open acid statin into portalcirculation, penetration by the open active statin into hepatocytes toachieve enhanced efficacy and systemic exposure consisting of open acidmoieties. Without being bound to any theory, it is believed thatmaintaining the statin in its open acid form in the body reduces thepotential for drug interactions between statins (whose metabolism isCYP3A4-mediated) and other active agents (that inhibit this CYP3A4enzymatic pathway), thereby providing enhanced efficacy of thecomposition disclosed herein.

As disclosed herein, the pharmaceutical composition also includes atleast one additional material exhibiting at least oneanti-hypercholesterolemic effect. The material of choice can be lipidlowering compounds or agents having other pharmaceutical activities, oragents having both lipid lowering effects and other pharmaceuticalactivities. Suitable materials will be preferably water-soluble.Nonlimiting examples of additional active agents that can beadvantageously employed in the formulation disclosed herein will bewater soluble and can include HMG-CoA reductase inhibitors, squaleneepoxidase inhibitors, squalene synthetase inhibitors (also known assqualene synthase inhibitors), acyl-coenzyme A, cholesterolacyltransferase (ACAT) inhibitors including selective inhibitors ofACAT-1 or ACAT-2, as well as dual inhibitors of ACAT-1 and ACAT-2,microsomal triglyceride transfer protein (MTP) inhibitors, probucol,niacin, cholesterol absorption inhibitors such as SCH-58235, also knownas ezetimibe and1-(4-fluorophenyl)-3(R)-3(S)-(4-fluorophenyl)-3-hydroxypropyl),4(S)-4-hydroxyphenol (−2-azetidinone) described in U.S. Pat. Nos.5,727,115 and 5,846,966, bile acid sequestrants, LDL, (low densitylipoprotein) receptor inducers, platelet aggregation inhibitors (forexample glycoprotein IIb/IIa fibrinogen receptor antagonists andaspirin. Human peroxisome proliferator activated receptor gamma (PPARγ)agonists may also be employed including the compounds commonly referredto as glitazones, for example troglitazone, pioglitazone, androsiglitazone, and those compounds included within the structural classknown as thiazolidinediones, as well as those PPARγ agonists outside thethiazolidinedione structure class, PPARα agonists such as clofibrate,fenofibrate, gemfibrozil, bezafibrate, and ciprofibrate, PPAR dual α/γagonists, vitamin B₆ (also known as pyridoxine), Vitamin B₁₂ (also knownas cyanocobalamin), folic acid in its water-soluble pharmaceutical saltor ester, such as sodium salt and the methylglucamine salt, anti-oxidantvitamins such as vitamin C and E and beta-carotene, beta-blockers,angiotensin II antagonists such as losartan, angiotensin convertingenzyme inhibitors such as enalapril and captopril, calcium channelblockers such as nifedipine and diltiazem, endothelial antagonists, andthe like. Other non-limiting examples of water soluble therapeuticagents include compounds associated with anti-retroviral therapies suchas those employed in the treatment of AIDS infected patients to treatlipid abnormalities associated with such treatment. These may includeHIV protease inhibitors such as indinavir, nelfinavir, ritinavir andsaquinavir.

More particularly, it is contemplated that the therapeutic agent used inconnection with the dihydroxy open acid salt of the suitable statin willinclude at least one of fibrates, bile acid sequestrants, and nicotinicacid or niacin. As used herein, “fibrates” refer to a class of lipidlowering drugs used to treat various forms of hyperlipidemia (elevatedserum triglycerides) that may be associated with hypercholesterolemia.The fibrates of choice are water-soluble compounds having the effect oftreating people with very high triglyceride levels through thelipoprotein lipase-mediated effect on lipolysis and by reducingtriglyceride production in the liver. The fibrates of choice may alsoincrease HDL-C by regulating apolipoprotein (apo)AI and (apo)AII geneexpression. The fibrates of choice, in addition to alterations in plasmaHDL-C levels, can induce emergence of large, cholesteryl ester-rich HDL.Fibrates can be defined as PPAR-alpha agonists (peroxisome proliferatoractivated receptor alpha agonists), including fibric acid derivativesand pharmaceutically acceptable salts and esters of such fibric acidderivatives, such as clofibrate, the ethyl ester ofp-chlorophenoxyisobutyrate. Fibric acid derivatives lower the levels oftriglyceride-rich lipoproteins, such as VLDL, raise HDL levels, and havevariable effects on LDL levels. The effects on VLDL levels appear toresult primarily from an increase in lipoprotein lipase activity,especially in muscle. This leads to enhanced hydrolysis of VLDLtriglyceride content and an enhanced VLDL catabolism. Fibric acid agentsalso may alter the composition of the VLDL, for example, by decreasinghepatic production of apoC-III, an inhibitor of lipoprotein lipaseactivity. These compounds are also reported to decrease hepatic VLDLtriglyceride synthesis, possibly by inhibiting fatty acid synthesis andby promoting fatty acid oxidation as a result of peroxisomalproliferation.

Fibrate derivatives include but are not limited to the salts ofclofibrate, gemfibrozil, fenofibrate, ciprofibrate, and bezafibrate. Thestructure of each is represented below:

Fenofibrate is commercially available as Tricor capsules. Each capsulecontains 67 mg of micronized fenofibrate. Fenofibrate regulates lipids.Fenofibric acid, the active metabolic of fenofibrate, lowers plasmatriglycerides apparently by inhibiting triglyceride synthesis, resultingin a reduction of VLDL released into the circulation, and also bystimulating the catabolism of triglyceride-rich lipoprotein (i.e. VLDL).The recommended daily dose of fenofibrate is 67 mg.

Clofibrate is commercially available as Atromid-S capsules. Each capsulecontains 500 mg of clofibrate. Clofibrate lowers elevated serum lipidsby reducing the very low-density lipoprotein fraction rich intriglycerides. Serum cholesterol may be decreased. It may inhibit thehepatic release of lipoproteins (particularly VLDL) and potentiate theaction of lipoprotein lipase. The recommended daily dose of clofibrateis 2 grams, administered in divided doses.

Gemfibrozil is commercially available as Lopid tablets. Each tabletcontains 600 mg of gemfibrozil. Gemfibrozil is a lipid regulating agentthat decreases serum trigylcerides and very low density lipoproteincholesterol, and increases high density lipoprotein cholesterol. Therecommended daily dose of Gemfibrozil is 1200 mg, administered in twodivided doses.

Fibrates include PPAR-alpha agonists which may also act as agonists forPPAR-gamma and/or PPAR-delta subtypes. PPAR-alpha, PPAR-gamma andPPAR-delta agonists may be identified according to an assay described inU.S. Pat. No. 6,008,239, pharmaceutically acceptable salts and esters ofPPAR-agonists are likewise included within the scope of this invention.

Other fibrates may be employed as desired or required. These include,but are not limited to, materials such as bezafibrate and ciprofibrate.The fibrate employed in the composition disclosed herein may be awater-soluble derivative of fenofibrate(2-[4-)4-chlorobenzoyl)phenoxy]-2-methyl-propionic acid-1-methylethylester. Fenofibrate is a prodrug that is essentially insoluble in water.Fenofibrate is typically absorbed and then hydrolyzed by tissue andplasma esterases to fenofibric acid, the active metabolite. It is thisfenofibric acid that is the active species responsible forpharmacological activity of fenofibrate. In the composition disclosedherein, it is contemplated that the acid derivative of fenofibrate canbe employed in connection with the dihydroxy acid salt of a statin orstatins. In the broadest embodiment, suitable pharmaceuticallyacceptable salts of fibric acid shall include, but not be limited to,cationic salts such as sodium, potassium, aluminum, calcium, lithium,magnesium, zinc, and tetramethylammonium, as well as those salts formedfrom amines, such as ammonia, ethylenediamine, N-methylglucamine,lysine, arginine, ornithine, choline, N,N′ dibenzylethylenediamine,chloroprocaine, diethanolamine, procaine, N-benzylphenethylamine,3-P-chlorobenzyl-2-pyrolidone-1′-yl-methylbenzimidazole, diethylamine,piperazine, morpholine, 2,4,4-trimethyl-2-pentamine, andtris(hydroxymethyl)aminomethane, as well as pharmaceutically acceptableesters to include, but not be limited to, C₁₋₄alkyl and C₁₋₄alkylsubstituted with phenyl-dimethylamino-N acetylamino groups.

The effects of fenofibric acid seen in clinical practice have beenexplained in vivo in transgenic mice and in vitro in human hepatocytecultures by the activation of peroxisome proliferator activated receptoralpha (PPARα). Through this mechanism, fenofibrate increases lipolysisand elimination of triglyceride-rich particles from plasma by activatinglipoprotein lipase and reducing production of apoprotein C-III (aninhibitor of lipoprotein lipase activity). The resulting fall intriglycerides produces an alteration in the size and composition ofLDL-C from small, dense particles (which are thought to be atherogenicdue to their susceptibility to oxidation), to large buoyant particles.These larger particles demonstrate greater affinity for cholesterolreceptors and are catabolized rapidly. It is also contemplated thatactivation of PPARα also induces an increase in the synthesis ofapoproteins A-I, A-II, and HDL-C.

The therapeutic agent can also be a bile acid sequestrant. Bile acids,the major components of bile, are produced in the liver and are createdfrom cholesterol. Once secreted into the small intestine, the majorityof bile acids are reabsorbed and neutralized. The body must then make upfor this bile acid loss by manufacturing more, thereby using up more ofthe cholesterol supplied. Bile acid sequestrants bind bile acids in theintestine, resulting in an interruption of the reabsorption of bileacids thereby reducing the reabsorption efficiency from an amount ofapproximately 90% to levels lower than this. Nonlimiting examples ofavailable bile acid sequestrants include, but are not limited to,cholestyramine, colestipol, described in U.S. Pat. No. 3,383,281 andcolesevelam.

These and other suitable materials, when orally administered to amammalian host, form complexes with bile acid conjugates in theintestine and are effective in blocking resorption of bile acids fromthe intestine. The compound and sequestered bile acids are subsequentlyexcreted from the body in fecal matter thereby increasing the rate atwhich bile acids are eliminated from the body. Other factors beingequal, an increase in the rate at which bile acids are eliminated fromthe body tends to lower plasma cholesterol level by accelerating theconversion of cholesterol to bile acids in order to maintain a constantsupply of bile acids. A portion of the cholesterol for this increasedsynthesis of bile acids is supplied by removal of cholesterol from theblood plasma.

Orally administered single compound bile acid sequestrants are typicallypositively charged resins that bind to negatively charged bile acids inthe intestine. Because the resins cannot be absorbed from the intestine,they are excreted carrying the bile acids with them. Conventional use ofsuch resins accomplishes a lowering in serum cholesterol levels of 20%or less. As bile acid sequestrant materials are never absorbed into thebody, they have few systemic side effects. However, bile acid bindingresins typically come as granules that must be thoroughly mixed withwater or juices and taken two to three times daily. These resins mayalso bind to other medications being taken. Thus a carefully planneddosing regimen must be developed by the patient and physician in orderto obtain maximum therapeutic benefit and avoid adverse interactionswith other medications.

It has been found, quite unexpectedly, that bile acid sequestrants usedin concert with HMG CoA reductase inhibitors such as dihydroxy openacids salts of statins can exhibit increased potency in lowering serumcholesterol levels, particularly in patients with markedly !elevatedplasma levels of LDL-C. It has been found, quite unexpectedly, thatformulations containing bile acid sequestrants and dihydroxy open acidsalts of statin as formulated herein exhibit synergistic actions tolower LDL-C by levels approaching 50 percent, while raising HDL-C byamounts between 10 and 20 percent. The performance can be furtherenhanced, particularly with regard to elevation of the HDL cholesterollevels when the formulation is further compounded with nicotinic acid.

Nicotinic acid also known as niacin or 3-pyridine carboxylic acid can beutilized in connection with the dihydroxy open acid salt of a statin inanticholesterolemic applications. Therefore, it has been known that Bcomplex vitamins, such as nicotinic acid or niacin, when utilized inhigh doses, can lower the rate of cholesterol synthesis. Niacin can havea variety of effects on lipid metabolism. It raises HDL-C levels by asmuch as 30 to 35 percent, both by reducing lipid transfer of cholesterolfrom HDL-C to VLDL, and by delaying HDL-C clearance. Another favorableproperty of nicotinic acid or niacin is a reduction in plasma fibrinogenlevels. Nicotinic acid is effective in patients withhypercholesterolemia and in combined lipidemia associated with normaland low levels of HDLC hypoalphalipoproteinemia). Typically, the HDL-Craising properties of nicotinic acid when used alone occur with dosagesof 1 to 1.5 grams/day and the VLDL and LDL lowering effects aretypically seen with higher doses (3 grams/day for example).

While niacin may sound like a perfect cholesterol-lowering drug, thefrequency of minor but poorly tolerated side effects greatly limits itsusefulness. Intense flushing sensations, nausea, and bloating are themost common patient complaints. While these effects can be mitigated bystarting on a very low dose and slowly titrating to a higher effectivedose, this process is tedious and not always fully satisfactory oreffective. As with statin drugs, liver function must be monitored byperiodic testing. Presentation of gout and gout-like symptoms in acertain percentage of the patient population probably indicates thatniacin should be avoided. Nicotinic acid is available in severalformulations that include immediate-release and sustained releaseformulations such as Niacore® and Niaspan®.

The various compounds and formulations function to affect serumcholesterol through various pathways. While fibrates and niacin havebeen proposed as therapies to raise HDL-C, fibrates raise HDL-C levelsby an average of 5 to 30 percent (predominantly in the HDL-3subfraction). The fibrates, particularly gemfibrozil and fenofibrate,appear to raise HDL levels by activating PPARα, which in turn enhancesexpression of HDL-regulating genes apoliproteins, A-I and A-II,lipoprotein lipase, and ABA 1. Niacin appears to reduce hepatic removalof the HDL apolipoprotein A-1 and hepatic lipase activity resulting inhigher levels of HDL-C and, HDL2 subfraction. Heretofore, when suchmaterials were used in combination therapy with statins, both statin andadded therapeutic agent were hydrophobic materials. Prior to 1987, thelipid-lowering regimen (armamentarium) was limited essentially to lowsaturated fat and cholesterol diet, bile sequestrants such ascholestyramine and colestipol, nicotinic acid (niacin), fibrates, andprobucol. Unfortunately, all of these treatments had limited efficacy ortolerability or both. Today the most frequently described class ofcholesterol lowering drugs, the HMG-CoA reductase inhibitors or statins,act by inhibiting an enzyme that plays all important role in cholesterolsynthesis. Statins have functioned well in decreasing the level of LDL-Cand have demonstrated a corresponding decrease in coronary heart diseaseand total mortality. Reductions in myocardial infarctions,revascularization procedures, stroke, and peripheral vascular diseasehave also been demonstrated. The statins have also been widely acceptedas the easiest of the cholesterol lowering drugs to use, as theirresponse rate is highly predictable, and their side-effect rate is low.Occasionally aches or nausea are the most common reasons for stoppingthese drugs. However, severe muscle or liver inflammation can occur andcan progress to myalgias, myopathy and/or life threateningrhabdomyolyis. Thus, these drugs must be closely monitored.

Introduced in 1987, lovastatin was the first statin based HMG-CoAreductase inhibitor. A similar agent, pravastatin, followed in 1991,along with simvastatin, a semisynthetic compound consisting oflovastatin plus an extra methyl group. In addition, there are now avariety of totally synthetic HMG-CoA reductase inhibitors, includingfluvastatin, atorvastatin, and rosuvastatin. The basic material,lovastatin, is a white, lipophilic, nonhygroscopic crystalline powderthat is insoluble in water (i.e., lipophilic) and sparingly soluble inethanol, methanol, and acetonitrile. Lovastatin, an inactive lactone, isa prodrug that is metabolically transformed to the corresponding(beta)-hydroxy acid. This is the active metabolite that inhibits HMG-CoAreductase. Lovastatin, as with simvastatin, atorvastatin, andcerivastatin, are all substrates of CYP3A4, and are extensivelymetabolized on first pass through the liver. On the other hand,hydrophilic statins, like fluvastatin and pravastatin, are metabolizedby CYP2C9 and pravastatin, not significantly metabolized by CYP, arecomparatively devoid of incidence of myalgias, myopathy, orlife-threatening rhabdomyolysis.

Optimal LDL-C levels have been set at 100 mg/dL and 115 mg/dL for highrisk patients by US and European guidelines respectively. To achievethese therapeutic target values for LDL-C, statins have become amainstay in the treatment of hyperlipidemia. These statements arerecommended as first-line pharmacological therapy in the majority ofhyperlipidemic patients at increased risk of initial or recurrentmanifestations of coronary heart disease (CHD).

As discussed herein, it is contemplated that atherosclerosis underliesmost coronary artery disease and thus contributes to a major cause ofmorbidity and mortality of modern society. High levels of LDL-C (i.e.above 180 mg/dL) and low levels of HDL-C (below 35 mg/dL) have beenshown to be important contributors to atherosclerosis. Cholesterol andTG are part of lipoprotein complexes in the bloodstream. These complexescan be separated by an ultracentrifugation into HDL-C, LDL-C,intermediate density lipoprotein (IDL) cholesterol, and very low densitylipoprotein (VLDL) cholesterol fractions. Cholesterol and TG aresynthesized in the liver, incorporating into VLDL, and released into theplasma. High levels of total-C, LDL-C, and apolipoprotein B (apo-B), amembrane complex for LDL-C are considered to promote atherosclerosis,and decreased levels of HDL-C and its transport complex, apolipoproteinA. Cardiovascular morbidity and mortality can vary directly with thelevel of total-C and LDL-C and inversely with the level of HDL-C.

Atherosclerosis is a slowly progressive disease characterized by theaccumulation of cholesterol within the arterial wall. Theatherosclerotic process begins when LDL-C becomes trapped within thevascular wall. Oxidation of the LDL-C results in the bonding ofmonocytes to the endothelial cells lining the vessel wall. Thesemonocytes are activated and migrate into the endothelial space wherethey are transformed into macrophages, leading to further oxidation ofLDL-C. The oxidized LDL-C is taken up through the scavenger receptor onthe macrophage leading the formation of foam cells. A fibrous cap isgenerated through the proliferation and migration of arterial smoothmuscle cells, thus creating an atherosclerotic plaque. Lipids depositingin atherosclerotic legions are derived primarily from plasma apo Bcontaining lipoproteins. These include chylomicrons, LDL-C, IDL, andVLDL. This accumulation forms bulky plaques that inhibit the flow ofblood until a clot eventually forms, obstructing an artery and causing aheart attack or stroke.

LDL-C and HDL-C are the major cholesterol carrier proteins. LDL-C isresponsible for the delivery of cholesterol from the liver, where it issynthesized or obtained from dietary sources to extrahepatic tissues inthe body. HDL-C is responsible for “reverse cholesterol transport” fromextrahepatic tissues to the liver where it is catabolized andeliminated.

Thus, while statins used independently have been recommended asfirst-line pharmacological therapy in the majority of hyperlipidemicpatients at increased risk of initial or recurrent manifestations ofcoronary heart disease, the use of statins in clinical practice hasachieved observed reductions in all LDL-C levels that are significantlyless than those theoretically obtainable. The exact reason for thisdisappointing achievement is not known. However, it is theorized thatmany physicians are reluctant to titrate up statin treatment at the highdoses because of known or perceived issues of tolerability and/orsafety. Reluctance can also be attributed to perception that the higheststatin dosages lack sufficient efficacy in the most severedyslipidemias. In some surveys, of risk factor management of patientswith established coronary heart disease, it is believed that only halfof those patients receiving lipid-lowering statin therapy have attainedrecommended lipid treatment goals.

As indicated previously, no single drug, such as the statins, as yetaddresses all lipid abnormalities. Various combination therapies,particularly combination therapies employing statin and fibrates thatare complementary and additive have been proposed to address overalllipid abnormalities. As indicated previously, however, statins andcompounds such as fibrates must be dosed individually on specific andcomplementary dosing regimens to ensure maximum and patient safety.While statins inhibit HMG CoA reductase, fibrates work on a differentmechanism by activating peroxisome proliferator-activated receptor-alpha1 (PPARα1) in the liver thereby improving the plasma transport rates ofseveral lipoproteins. Other anti-atherothrombotic effects of fibratesinclude the inhibition of coagulation and enhancement of fibrinolysis,as well as the inhibition of inflammatory mediators involved inatherogenesis.

While the statin/fibrate therapy regimen has been proposed in situationswhere monotherapy does not achieve lipid targets or is impractical,statin-fibrate combination therapies can be difficult to administer andmaintain even though these combination therapies can substantiallyreduce LDL-C and triglyceride and increase HDL-C levels. Currentstatin-fibrate combination therapies strongly recommend separate dosingof the two drugs, for example, weekly administration of fibrate anddaily statin treatment or fibrates prescribed in the morning and astatin at night to minimize peak dose interactions. In contrast, it hasbeen found, quite unexpectedly that the formulation disclosed hereincontaining a dihydroxy-open acid statin salt in combination with afibrate, such as a water-soluble fibrate, can be administered in asingle dose form to achieve significant decreases in LDL-C andtrigylcerides and, most importantly, increases in HDL-C levels.

The instant pharmaceutical combination comprised a water-soluble HMG-CoAreductase inhibitor in combination with an additional water-solubletherapeutic material capable of administration in a singlepharmaceutical dosage formulation containing both materials. The instantpharmaceutical combination is understood to include all these regimens.Administration in these various ways are suitable for the presentinvention as long as the beneficial pharmaceutical effect of the HMG-CoAreductase inhibitor and other therapeutic agent are realized by thepatient at substantially the same time. Such beneficial effect ispreferably achieved when the target blood level concentrations of eachactive drug are maintained at substantially the same time. It iscontemplated that the materials be co-administered concurrently on aonce-a-day dosing schedule; however, varying dosing schedules, such asonce, twice or more times per day is also encompassed herein. It iscontemplated that a single dosage formulation will provide conveniencefor the patient, which is an important consideration especially forpatients who already have coronary heart disease and may be in need ofmultiple medications.

The term “patient” includes mammals, especially humans, who take anHMG-CoA reductase inhibitor in combination with another therapeuticagent for any of the uses described herein. Administering of the drugcombination to the patient includes both self-administration andadministration to the patient by another person.

The term “therapeutically effective amount” is intended to mean thatamount of a drug or pharmaceutical agent that will elicit the biologicalor medical response of a tissue, a system, animal or human that is beingsought by a researcher, veterinarian, medical doctor or other clinician.The term “prophylactically effective amount” is intended to mean thatamount of a pharmaceutical drug that will prevent or reduce the risk ofoccurrence of the biological or medical event that is sought to beprevented in a tissue, a system, animal or human by a researcher,veterinarian, medical doctor or other clinician. The dosage regimenutilizing water-soluble HMG-CoA reductase inhibitor in combination withanother water soluble therapeutic agent with a variety of factorsincluding type, species, age, weight, sex, and medical condition of thepatient; the severity of the condition to be treated; the route ofadministration; the renal and hepatic function of the patient; and theparticular compound or salt or ester thereof employed. Since twodifferent active agents are being used together in a combinationtherapy, the potency of each of the agents and the interactive effectsachieved by combining them together should also be taken into account.

As used herein, a suitable dose form can be any modality that candelivery the active ingredients to the user in a manner suitable foruptake by the user. Thus, it is contemplated that the dose form can bean oral dose form, an implantable form, time released form, or the like.As articulated further, it is contemplated that the dose form will be anoral dose form. Dosage amounts per dose form will vary depending uponfactors including, but not limited to, standard atherosclerotic diseasefactors, compound potency, and the like. It is also contemplated thatthe active drug may be administered in divided doses, for example, fromone to four times daily, as desired or required. However, a single dailydose of the active compounds can be preferable in many applications.

Non-limiting examples of standard atherosclerotic disease factors thatcan be used in determining dosing include known risk factors such ashypertension, smoking, diabetes, low levels of high density lipoprotein(HDL), cholesterol, and a family history of atheroscleroticcardiovascular disease. Published guidelines for determining those whoare at risk of developing atherosclerotic disease can be found invarious sources such as the National Cholesterol Education Program,Second report of the Expert Panel on Detection, Evaluation, andTreatment of High Blood Cholesterol in Adults (Adult Treatment PanelII), National Institute of Health, National Heart Lung and BloodInstitute, NIH Publication No. 93-3095 (September 1993 abbreviatedversion; Expert Panel on Detection, Evaluation, and Treatment of HighBlood Cholesterol in Adults, Summary of the second report of theNational Cholesterol Education Program (NCEP) Expert Panel on Detection,Evaluation, and Treatment of High Blood Cholesterol in Adults (AdultTreatment Panel II), JAMA, 1993, 269, pp. 3015-23. People who areidentified as having one or more of the above-noted risk factors areintended to be included in the group of people considered at risk fordeveloping atherosclerotic disease. People identified as having one ormore of the above-noted risk factors, as well as people who already haveatherosclerosis, are intended to be included within the group of peopleconsidered to be at risk for having an atherosclerotic disease event.

The active drug compounds employed in the instant therapy can beadministered in various oral forms including, but not limited to,tablets, capsules, pills, powders, granules, elixirs, tinctures,suspensions, syrups, and emulsions. It is contemplated that the activedrug compounds can be delivered by any pharmaceutically acceptable routeand in any pharmaceutically acceptable dosage form. These include, butare not limited to the use of oral conventional rapid-release, timecontrolled-release, and delayed-release pharmaceutical dosage forms. Theactive drug components can be administered in a mixture with suitablepharmaceutical diluents, excipients or carriers (collectively referredto herein as “carrier” materials suitably selected to with respect tothe intended form of administration. As indicated, it is contemplatedthat oral administration can be effectively employed. Thus, tablets,capsules, syrups, and the like as well as other modalities consistentwith conventional pharmaceutical practices can be employed.

In instances in which oral administration is in the form of a tablet orcapsule, the active drug components can be combined with a non-toxicpharmaceutically acceptable inert carrier such as lactose, starch,sucrose, glucose, modified sugars, modified starches, methylcelluloseand its derivatives, dicalcium phosphate, calcium sulfate, mannitol,sorbitol, and other reducing and non-reducing sugars, magnesiumstearate, stearic acid, sodium stearyl fumarate, glyceryl behenate,calcium stearate and the like. For oral administration in liquid form,the active drug components can be combined with non-toxicpharmaceutically acceptable inert carriers such as ethanol, glycerol,water and the like. When desired or required, suitable binders,lubricants, disintegrating agents and coloring and flavoring agents canalso be incorporated into the mixture. Stabilizing agents such asantioxidants, for example butylated hydroxyanisole (BHA),2,6-di-tert-butyl-4-methylphenol (BHT), propyl gallate, sodiumascorbate, citric acid, calcium metabisulphite, hydroquinone, and7-hydroxycoumarin can also be added to stabilize the dosage forms. Othersuitable compounds can include gelatin, sweeteners, natural andsynthetic gums such as acacia, tragacanth, or alginates,carboxymethylcellulose, polyethylene, glycol, waxes and the like.

Where desired or required, the active drug can also be administered inthe form of liposome delivery systems, such as small unilamellarvesicles, large unilamellar vesicles and multilamellar vesicles.Liposomes can be formed from a variety of phospholipids, such ascholesterol, stearylamine or phosphatidylcholines.

It is also contemplated that the active drugs may be delivered by theuse of monoclonal antibodies as individual carriers to which thecompound molecules are coupled. The active drug may also be coupled withsoluble polymers such as targetable drug carriers. Non-limiting examplesof such polymers can include polyvinyl-pyrrolidone, pyran copolymer,polyhydroxy-propyl-methylacrylamide-phenol,polyhydroxy-ethyl-aspartamide-phenol or polyethyleneoxide-polylysinesubstituted with palmitoyl residues. Furthermore, the active drugs maybe coupled to a class of biodegradable polymers useful in achievingcontrolled release of a drug, for example polylactic acid, polyglycolicacid, copolymers of polylactic and polyglycolic acid, polyepsiloncaprolactone, polyhydroxybutyric acid, polyorthoesters, polyacetals,polydihydropyrans, polycyanoacrylates, and crosslinked or amphipathicblock copolymers of hydrogels.

Once administered, the active drugs work on the hepatic metabolism invarious manners. Hepatic metabolism is served by a superfamily ofoxygenases known as Cytochrome P 450s. These enzymes add a functionalgroup to a drug, chemical or endogenous molecule to increase at leastone of polarity, excretion from the body or interaction with similarenzymes. The most distinguishing characteristic of the Cytochrome P450family is its great diversity and ability to react with almost anychemical species. The superfamily, referred to as the CYP enzymes, issubdivided according to the degree of homology in the amino acidsequences. Families are further divided into subfamilies, which aredesignated by a letter after the number, examples of these include CYP2Cand CYP2D subfamilies. Members of each family typically have more than55% homology with one another. Finally, individual members are given anadditional number (for example CYP3A4) to identify a specific enzymepathway. Over 70 CYP families have been identified to date of which 14are known to occur in all mammals. Of the 26 mammalian subfamilies, theCYP2C, CYP2D, and CYP2A sub families are involved in the metabolism ofmost clinically relevant drugs.

The CYP3A sub family, like CYP2D6, is involved in the metabolism of alarge number of drugs and other chemicals and is involved in manydrug-drug and drug-food interactions. It is the most abundant of all theCytochrome P450s in the human liver with enzyme amounts of 25 to 28%being common and amounts ranging as high as 70% being found in certaininstances. Additionally, CYP3A is widely expressed throughout thegastrointestinal tract, kidneys and lungs. More than 150 drugs are knownsubstrates of CYP3A4, the major CYP3A isozyme, including many of theopiate analgesics, steroids, antiarrhythmic agents, tricyclicantidepressants, calcium-channel blockers, macrolide antibiotics andcertain of the statins.

As indicated previously, statins are associated with two uncommon butimportant side effects, namely a symptomatic elevation in liver enzymesand skeletal muscle abnormalities. These skeletal abnormalities canrange from benign myalgias to myopathy exhibiting a tenfold elevation increatine kinase with muscle pain or weakness. The abnormalities can alsorange to life-threatening rhabdomyolysis. The incidents of myopathy inpatients taken statins alone is estimated to be 0.1 to 0.2% of thetreated population. Rhabdomyolysis is lower than that.

Myopathy is most likely to occur when statins are administered withother drugs or chemicals that compete with the statin through theCytochrome P450 (CYP3A4) enzyme system thereby elevating concentrationsof statin to the toxic range. Thus, there has been reported an incidenceof muscle disorder increase over tenfold when statins are administeredwith other therapeutic materials such as the fibrate, gemfibrozil,niacin, and the like. Adverse myopathies have also increased whenstatins are administered with erythromycin, itraconazole, cyclosporine,and diltiazem. Also, various substances found in grapefruit juice, greentea, and other foods are potent inhibitors of CYP3A4 and are known to beresponsible for many drug interactions.

Without being bound to any theory, it is believed that myopathy is adirect consequence of HMG CoA reductase inhibition and is dosedependent. As the statins inhibit HMG CoA reductase, a variety ofmetabolic intermediates required for post-translational modification ofa variety of regulatory proteins which are generated in the process ofcholesterol synthesis are also depleted. Non-limiting examples of suchregulatory proteins include mevalonate, ubiquinone, farnesol, andgeranylgeraniol. The depletion of such metabolic intermediates has beenpostulated to potentially play a roll in statin-associated myotoxicity.Additionally, lipophilic statins are more readily able to enter skeletalmuscle and accumulate than the non-lipophilic or hydrophilic statins.While highly lipophilic lactone pro drugs, such as lovastatin andsimvastatin, are highly extracted by the hepatic tissues, theircorresponding dihydroxy acid forms are hydrophilic and exhibit poortissue penetration.

To further illustrate the present invention, reference is made to thefollowing examples. These examples are set forth for purposes ofillustration and are not considered limitative of the present invention.

EXAMPLE 1

In order to prepare a suitable HMG CoA reductase inhibitor, the materiallovastatin was prepared. Lovastatin was produced during the fermentationprocess, for example by Aspergillus terreus ATCC 20542. Thus, using asuitable fermentation medium, a fermentor and fermentation conditions,the microorganism produce the compound which was primarily localized inthe mycelia. In this regard, at harvest, the fermentation broth wascentrifuged or filtered to recover the mycelial cake; the filtrate orsupernatant did not contain the drug and thus was discarded.

After the broth was transferred to the holding tank, the pH of the brothwas adjusted to 2.0 by adding HCl (about 0.75-1.0% of concentrated HClby volume of broth). The HCl was added slowly while stirring.

The drug in the mycelial cake is extractable with an organic solvent.Preliminary data indicate that solvent extraction of the drug is moreefficient with a dried mycelial cake than with a wet cake. In thisregard, the filtered wet cake is dried prior to solvent extraction.Drying of the mycelial cake may be accomplished by simple air drying orby the aid of heat (e.g., sludge dryer). The color of the mycelia caketurns from tan to dark brown as it dries. Completeness of drying isdecided by physical inspection, where there is no obvious moisturepresent in the sample.

The drug lovastatin is soluble in most organic solvents (e.g., methanol,acetone, ethyl acetate, methylene chloride, methylethylketone, etc.).For purposes of this process, methylethylketone (MEK) was employed forextracting the drug from the dried mycelial cake.

The dried mycelial cake was transferred to a stainless steel holdingtank. To 1 part of the dried mycelial cake, about 4.0 parts MEK (e.g., 1kg of dried mycelial cake: 4.0 liters or 1 gal of MEK) was added.

The dried mycelial cake can be soaked in MEK for at least overnight,with occasional stirring, to allow for ample extraction of the drug.After a certain period of soaking, the mixture can be filtered and thesolvent extract recovered. The spent cake was rinsed with 2 parts freshMEK and the MEK extracts were pooled.

The MEK extract contained crude lovastatin along with other extraneouscompounds. The extract was concentrated, in vacuo, into an oilysubstance, using a thin film (e.g., Luwa) evaporator. To the oilyconcentrate, a filter aid (e.g., diatomaceous earth) was added at about1.0% by weight of the volume of the pooled MEK extract. The filter aidwas mixed into the oil until it turns into a dry solid mixture. Theresidual MEK was evaporated by air drying. To the dried mixture, 30% (byweight) of powdered activated carbon (e.g., Calgon's Colorsorb) wasadded and the admixture was mixed thoroughly.

The carbon-sample mixture was slurried into ethylacetate (e.g. about 2-4parts by weight of carbon-sample mixture/volume ethylacetate).

Purification can be accomplished by any means such as a chromatographicsystem for the purification of lovastatin involving carbon and activatedbauxite in the manner as follows:

The ethylacetate slurry was poured on top of a chromatographic columnand eluted with ethylacetate. The activated carbon in the slurry adsorbsthe extraneous color (e.g., brownish red color), and the activatedbauxite in the column further adsorbs miscellaneous impurities.

The polypropylene column (1.0′ diameter×4.0′ height) was inspected forcleanliness and dryness. A glass wool or synthetic fiber filter liningwas placed at the bottom of the column. The column was derived usingthree kilograms each of the different column components (e.g., filteraid, activated carbon, activated bauxite). Filter aid was added first,compressed by tapping. Activated carbon (e.g., Colorsorb) was thenadded, and the column tapped to compress. The activated bauxite wasadded, followed by another layer of filter aid. After the column waspacked, the ethylacetate slurry was poured into the head-space of thecolumn. The solvent was allowed to drain to the top of the carbonmixture at the top of the column. Three kilograms of additional filteraid (diatomaceous earth) was added to the top of the column to layer or“seal” off the carbon mixture.

Add batches of 20-L ethylacetate were added to elute the column, eachtime allowing the solvent to drain on top of the column before addingthe next 20 liter batch. The eluate was recovered separately and thevolume recovered was recorded. Each eluate was assayed for drug contentand recorded below. Fresh ethylacetate was fed or added to the columnuntil the entire drug has been eluted.

The rich-cut fraction of ethylacetate eluted from the chromatographiccolumn is largely pure lovastatin. Although the drug is soluble in mostorganic solvents, if it is concentrated enough it precipitates in coldethylacetate and can be washed with hexane or petroleum ether.

The ethylactate eluate was concentrated, in vacuo. Concentration may becarried out in a round flask evaporator or with a thin film (e.g., Luwa)evaporator.

As the ethylacetate was evaporated, crystals of lovastatin were formed.As crystals are formed, the concentrated solution was transferred in acold room.

The concentrated solution was refrigerated for 1-3 days to complete thecrystallization process. The wet crystals were harvested by filtration.The filtrate or mother liquid was recovered and the volume is recorded.The mother liquid may be further processed to recover additional drug.

Hexane was added to the crude crystals to wash off any residual color toobserve white crystals. The hexane was removed by filtration and isrecovered and distilled.

The lovastatin crystals were allowed to air dry to remove residualhexane and the crystals were recovered. The resulting crystals were thelactone compound form of lovastatin.

EXAMPLE 2

Salts of lovastatin can be prepared in the following manner:

The lactone compound isolated in Example 1 is conveniently transformedin to the dihydroxy-acid salts when hydrolyzed with bases such as NaOHor KOH to yield the corresponding sodium and potassium salts,respectively. The use of bases with the pharmaceutically acceptablecations affords salts of these cations.

A 10-gm lovastatin crystal isolated from Example 1, and a molarequivalent of NaOH were added while stirring at room temperature. Afterthe mixture turns into a solution, it was taken to dryness in vacuo toyield the sodium salt of the free acid form hereinafter referred to asCompound I.

EXAMPLE 3

Preparation of the sodium salts of fibric-acid and niacin. The startingmaterials, fenofibrate, bezafibrate, and niacin are purchased from SigmaChemicals (St. Louis, Mo.). To about 50 ml of ethanol 10-gm fenofibratecrystals, and a molar equivalent of NaOH are added while stirring atroom temperature. After the mixture turns into a solution, it is takento dryness in vacuo to yield the sodium salt of the free acid form offenofibrate hereinafter referred to as Compound II.

In like manner, sodium salts of bezafibrate (Compound III) and niacin(Compound IV) are prepared using one equivalent of sodium hydroxide.

EXAMPLE 4

Evaluation of antilipidemic property in animal. Golden Syrian hamster,8-wk old (85-100 g) (Bio®F1B, Bio Breeders, Inc., Watertown, Mass.) wasthe animal model chosen for this study because of its similarities withhumans in lipoprotein metabolism and atherosclerosis Moreover, thehamster has plasma cholesteryl ester transfer protein (CETP) similar tohumans. Dietary fat saturation affects apolipoprotein gene expressionand high-density lipoprotein size distribution in golden Syrianhamsters.

The animals housed four per cage were fed Kaytee Supreme FortifiedHamster diet (Kaytee Products, Inc. Chilton, Wis.), with one part ratioof Heath High Energy suet (Heath Mfg., Cooperville, Mich.); water adlibitum. The animals were fed this diet for 1 week, and then given thedrug treatment for a 2-week duration. Drugs were administered by dailyoral gavage using 4:6 PEG/Cremaphore suspension vehicle for thewater-insoluble drugs (e.g., atorvastatin, lovastatin, simvastatin, andthe fibrates); the water-soluble drugs (dihydroxy-acid salts,pravastatin) were dissolved in water. Equivalent doses, based on a 70 kgman, were administered in the hamster. For example, a “10-mg dose” means10 mg/70 kg (0.143 mg/kg). Thus, the calculated final dose for a 100-gmhamster is 0.143 mg as well (0.143 mg/100-gm hamster X a factor of“10”), formulated in a 0.25 ml solution for oral gavage administration.Each test substance is administered to 2-3 animals; control animals didnot receive the drug and were used as reference. Body weights wererecorded prior to drug administration and every other day during thetest duration.

At termination, blood was collected from anesthetized hamsters and theserum is separated by centrifugation. Total serum cholesterol wasassayed using the Hitachi Diagnostics enzymatic kit for thedetermination of total cholesterol, LDL cholesterol, HDL cholesterol,and triglyceride (Analysis performed by: Lipid Analysis, Inc.,Springfield, Ill.).

TABLE 2 Comparison of antilipidemic activity of the dihydroxy-acid salt(Compound I and the currently marketed statins in a hamster animalmodel. % Decrease On: Total Cholesterol LDL-C HDL-C TriglycerideEquivalent Dose Equivalent Dose Equivalent Dose Equivalent Dose (mg)(mg) (mg) (mg) Drug 160 8 160 8 160 8 160 8 I 40.7 30.3 29.2 41.4 32.225.2 33.7 28.6 Lipitor (Atorvastatin) 43.0 28.6 54.4 28.5 30.7 33.3 53.035.8 Mevacor 36.6 19.4 54.4 22.4 26.7 20.4 34.4 21.8 (Lovastatin)Pravachol 23.0 22.4 33.3 29.9 17.3 20.4 25.9 18.8 (Pravastatin) Zocor(Simvastatin) 40.7 9.5 54.4 5.4 30.7 12.6 43.0 23.4

The dihydroxy-acid salt (Compound I) was found to be readily soluble inwater and was compared against the currently marketed cholesterollowering drugs (Lipitor, Mevacor, Zocor, and Pravachol) forantilipidemic profile. Compound I was found to be comparable withLipitor in lowering total cholesterol and trigylcerides, and better thanLipitor in lowering LDL-C particularly at 8 mg dose (Table 2).

TABLE 3 Comparison of antilipidemic activity of Compound I vs Lipitor ina hamster model. % Decrease On: Equivalent Dose Total Cholesterol LDL-CHDL-C Triglyceride (mg) Lipitor I Lipitor I Lipitor I Lipitor I 5.0 —14.8 — 14.7 — 5.6 — 4.5 10.0 18.2 12.6 17.9 23.7 20.7 12.4 5.0 6.8 20.012.3 20.9  8.9 22.4 15.9 20.7 4.8 23.6

A repeat side-by-side comparison between Compound I and Lipitor, thistime at 5-20 mg dose range confirmed the effectiveness of Compound I indecreasing LDL-C. Moreover, Compound I was effective at a dose as low as5 mg (Table 3).

TABLE 4 Antilipidemic activity of Compound I in combination with one ofCompounds II, III, and IV. % Decrease or Increase (i) On:Drug/Equivalent Dose CHOLES TRIG HDL-C LDL-C I (10 mg) +Niacin (150 mg)5.6 22.3i 1.18 8.9 (300 mg) 9.3 26.2i 13.8 16.6 (600 mg) 12.3 10.9i 17.219.3 +II  (50 mg) 10.3 47.9 8.0i 13.2 (100 mg) 12.8 63.9 3.4i 3.1 (200mg) 20.4 73.4 3.4i 33.6 +III  (50 mg) 19.4 61.2 3.5 20.9 (100 mg) 11.333.4 0 26.0 (200 mg) 27.2 51.7 13.4 33.2 +IV (150 mg) 0 41.7 11.1i 14.7i(300 mg) 6.6i 15.9 50.0i 27.4i (600 mg) 3.1i 47.1 9.6i 27.4i

Compound I and Lipitor were not effective in raising HDL-C. In thisregard, combinations of I with fibrates and niacin were evaluated. Sinceniacin and existing fibrates are not soluble in water, sodium salts wereprepared (Compounds II, III, and IV) and tested in combination withCompound I.

Table 4 shows the effect of Compound I (10 mg) combined with regularniacin and various fibric acid salts (150-600 mg). The niacin-Compound Icombination resulted in decreased total cholesterol, LDL-C, and HDL-C,and increased triglycerides. On the other hand, Compound I combined withCompound IV (water soluble form) resulted in significant decrease intriglyceride levels, but increased levels of LDL-C, HDL-C, and totalcholesterol.

In regard to Compound I (10 mg) combined with sodium fibrates (50-200mg), Compound I and Compound III in combination yielded significantdecreases in total cholesterol, triglycerides, HDL-C, and HDL-C;Compound I and II in combination yielded decreases in total cholesterol,triglyceride, LDL-C, and most interestingly significant increase inHDL-C (Table 3). Based on these data, it can be concluded that CompoundI at the 8-160 mg range is as good or better than Lipitor in reducingcholesterol, triglyceride, and LDL-C. Compound I reduced LDL-C by41.4-59.2% vs. 28.5-54.4% for Lipitor. On repeat experiment using 5-20mg dose range, Compound I confirmed its antilipidemic activity, reducingLDL-C by 22.4-23.7% vs 8.9-17.9% for Lipitor. Compound I exhibitedactivity at doses as low as 5 mg. The four currently marketed statins(e.g., Lipitor, Mevacor, Zocor, Pravachol) in combination with CompoundI did not show any increase in HDL-C. However, when Compound I (10 mg)was combined with Compound II (50-200 mg), HDL-C level was increased to3.4-8.0. Compounds III or IV, combined with Compound I also resulted inincreases in HDL-C level.

The results of the above examples confirm the claims for this inventionthat lovastatin, the parent compound is not water-soluble, whiledihydroxy-acid sodium salt, referred to as Compound I is water-soluble.The parent compound fenofibrate is not water soluble but the sodium saltreferred to as Compound II is water soluble. Compound I is more activethan the prodrug lovastatin, where Compound I is almost 2-fold moreactive than the parent lovastatin in reducing total cholesterol andLDL-C. Compound I as monotherapy was effective in reducing totalcholesterol, LDL-C, and triglyceride, and when combined with materialssuch as Compound II, a complementary additive therapeutic effect wasobserved not only by decreasing total cholesterol, LDL-C, triglyceride,but most importantly increasing the level of HDL-C at a relatively lowdose levels and ranges.

EXAMPLE 5

Crestor is a new synthetic statin and considered “superstatin” becauseof its effectiveness at low doses. In clinical studies, Crestor is nowfound to be the new gold standard among the statins: a 5 mg Crestor doseis equivalent to 20 mg Lipitor, 40 mg Zocor, 80 mg Mevacor or Pravachol.Thus, the drug combination of Compound I and Compound II was comparedwith Crestor. The animal model was Syrian Golden hamsters (F₁B strain,BioBreeders, Fitchburg Mass.). The animals approximately 8-10 weeks ofage were fed a non-purified chow-based hypercholesterolemic diet (HCD)containing 10% coconut oil and 0.1% cholesterol by weight for 2 weeksprior to initiation of the experimental treatments, and remain on thisdiet for the remainder of the study. Compounds I and II wereadministered by oral gavage (0.2 mL), once a day for 14 days. At day 14,blood samples were obtained after an overnight fast.

Desirable overall lipid profile (i.e., decreased level of cholesterol,triglyceride, LDL, and elevated HDL) was achieved with combinationformulations of Compounds I and II combo drugs (see Table 5). Theeffective doses found in this study were 1-3 mg of Compound I and 30-40mg of Compound III. This drug combination showed superior lipid profilewhen compared with Crestor: Crestor did not boost HDL, level and wasless effective in controlling cholesterol and LDL.

TABLE 5 Effect of Compounds I and II combo drugs on lipid profilecompared with Crestor. Type of Lipid/Percent increase (+) or decrease(−) Compound (dose)* HDL Cholesterol LDL Triglyceride I (1-3 mg) +(+)8-35 (−)3-19 (−)11-32 (−)11-44 II (30-40 mg) Crestor (3 mg) (−)8-16(−)13-(+)16 (−)19-(+)16 (−)35-51 *mg/70 kg man.

EXAMPLE 6

It is known that toxicity associated with statins and fibrates includeliver and kidney damage and muscle toxicity (rhabdomyolysis, myalgia,myopathy, and myositis). Thus, increasing dose combinations of CompoundsI and II were tested in Rattus norvegicus, outbred Sprague Dawley (fromHarlan) 10 rats/group (5 males and 5 females) to assess any associatedtoxicities. Age range at initiation of study was 8-14. Weight range atinitiation of study was 225-250 gm. Quarantine/acclimation was one week.Animals were randomized to groups based on weight. Number per cage was2-3. Environmental conditions: Conventional microisolator caging. Roomtemperature was maintained between 19 and 23° C. Relative humidify wasmaintained at 55-80%. The light/dark cycle was maintained on a 12 hourcycle. Animals were exposed to the test substance daily for 14 days (2weeks); and the doses were administered by gavage.

Gross necropsy was performed in the animals in the study. Tissues werecollected and examined for histopathology, e.g., liver, lung, heart(with aorta), thymus, lymph nodes, stomach, intestines, spleen, kidneys,adrenals, testes, ovaries, uterus, brain, and skeletal muscle. wasdetermined by the state of autolysis at the time of examination.Collected tissues were placed in formalin overnight and then sectionedand cassetted the following day.

Blood samples were collected by cardiac puncture, 24 hours after thelast treatment, as part of the necropsy protocol. Parameters examinedinclude hematocrit (HCT), hemoglobin (Hgb), total erythrocyte count(RBC), total white cell count (WBC), differential count, and plateletestimate; calculated mean corpuscular volume (MCV), mean corpuscularhemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC).

Also, at 16-18 hours after the last treatment, animals were placed inmetabolic cages and urine was collected (just prior to necropsy). Theurine samples were tested for presence of myoglobin.

Clinical Chemistry. Blood samples were collected by cardiac puncture, 24hours after the last treatment, as part of the necropsy protocol.Clinical chemistries were performed on all animals from which blood wascollected. Parameters examined included creatinine, alanineaminotransferase (ALT), alkaline phosphatase (ALK), creatinephosphokinase (CPK), and aldolase.

Results of this study provide reasonable evidence that the effectivetherapeutic combination of Compound I and Compound II (1-3 mg ofCompound I and 30-40 mg of Compound II) is a relatively safe andeffective to improve overall beneficial effect on all lipidabnormalities and possibly risk factors associated with coronary heartdisease. As shown in Table 6, the “no-observable-adverse-effect-level(NOAEL)” for the combination of Compounds I and II is below 1000 mg forCompound II and 10,000 mg for Compound II. The dose of 1,000 mg CompoundI and 10,000 mg Compound III can be considered the maximum tolerateddose (MTD). Combination therapy up to the MTD dose was well toleratedand no significant increases in serum liver and muscle enzymes werenoticed. The level of the enzymes associated with toxicities in theliver (ALT, ALK), kidney (creatinine), and muscle function (CPK,aldolase) appeared normal up to the MTD level. Also, all urinalysisresults were below 0.045 mg/dL of myoglobin, and hematology were withinthe normal range up to the MTD level.

TABLE 6 Toxicology profile of Compound I/II Combinations DISEASEMARKERS* Compound ALANINE ALKALINE CREATININE I/II CREATININE NH₃TRANSPHOS PHOS'KINASE ALDOLASE Combo** (MG/DL) (IU/L) (IU/L) (IU/L) (U/L)HISTOPATHOLOGY 20/200 0.4 48.0 142.0 312.0 22.0 All tissues appearnormal; no significant finding 200/2000 0.4 56.0 205.0 364.0 26.0Skeletal muscle, no significant finding; heart, myocardial in one rat500/5000 0.5 64.7 236.7 488.6 52.3 Cross sections of muscle fiber showsome variation in size but believed to be artifactual since CPK isnormal 1000/10000 0.4 63.0 240.2 522.3 68.2 Cross sections of musclefiber show some variation in size but believed to be artifactual sinceCPK is normal 2000/20000 Toxic Dose One surviving rat with clear damageControl 0.4 52.0 140.0 625.0 32.0 All tissues appear (Baseline) normal*Liver function (liver enzymes): Alanine aminotransferase (ALT) andAlkaline phosphatase (ALK). Kidney function: Creatinine Muscle function(if animals appear affected with myositis): Creatinine phosphokinase(CPK), aldolase (ALD) **mg/70 kg man.

While the invention has been described in connection with what ispresently considered to be the most practical and preferred embodiment,it is to be understood that the invention is not to be limited to thedisclosed embodiments but, on the contrary, is intended to cover variousmodifications and equivalent arrangements included within the spirit andscope of the appended claims, which scope is to be accorded the broadestinterpretation so as to encompass all such modifications and equivalentstructures as is permitted under the law.

1. A pharmaceutical composition comprising a therapeutically effectiveamounts of at least one HMG CoA reductase inhibitor present as a watersoluble dihydroxy-acid salt and at least one additional therapeuticagent.
 2. The pharmaceutical composition of claim 1 wherein theadditional therapeutic agent exhibits effects on at least one lipidabnormality presenting in a patient.
 3. The pharmaceutical compositionof claim 1 wherein the additional therapeutic agent includes at leastone of the HMG-CoA reductase inhibitors squalene oxidase inhibitors,squalene synthetase inhibitors, acyl-coenzyme A, cholesterolacyltransferase inhibitors, microsomal triglyceride transfer proteininhibitors, cholesterol absorption inhibitors, bile acid sequestrants,LDL receptor inducers, and platelet aggregation inhibitors.
 4. Thepharmaceutical composition of claim 1 wherein the additional therapeuticagent includes at least one of peroxisome proliferator activatedreceptor agonists, cholesteryl ester transfer protein modifiers, CETPmodifiers, long chain carboxylic acid compounds and long chaincarboxylic ether compounds.
 5. The pharmaceutical composition of claim 1wherein the additional therapeutic agent includes at least one ofperoxisome proliferator activated receptor gamma agonists, peroxisomeproliferator activated receptor alpha agonists, peroxisome proliferatoractivated receptor dual alpha/gamma agonists.
 6. The pharmaceuticalcomposition of claim 5 wherein the peroxisome proliferator activatedreceptor alpha agonist includes at least one water soluble salt of thefree acid form of a fibrate derivative.
 7. The pharmaceuticalcomposition of claim 1 wherein the fibrate is a water soluble salt ofthe free acid form at least one of clofibrate, gemfibrozil, fenofibrate,bezafibrate, and ciprofibrate.
 8. The pharmaceutical composition ofclaim 1 wherein the additional therapeutic agent includes at least oneof vitamin B₆, vitamin B₁₂, water soluble salts of folic acid, watersoluble esters of folic acid, vitamin C, vitamin E, betacarotene,beta-blocker agents, angiotensin II antagonists, calcium channelblockers, endothelial antagonists, and HIV protease inhibitors.
 9. Thepharmaceutical composition of claim 2 wherein the additional therapeuticagent is at least one of a bile acid sequestrant, a water-soluble saltof the free acid form of a fibrate, and a nicotinic acid.
 10. Thepharmaceutical composition of claim 9 wherein the fibric acid salt iswater soluble and is at least one of clofibrate, gemfibrozil,fenofibrate, bezafibrate, and ciprofibrate.
 11. The pharmaceuticalcomposition of claim 1 wherein the HMG-CoA reductase inhibitor is awater-soluble dihydroxy acid salt of a statin.
 12. The pharmaceuticalcomposition of claim 11 wherein the dihydroxy acid salt of a statinlactone prodrug has the general formula:

wherein R is a chromophore.
 13. The pharmaceutical composition of claim12 wherein the statin is selected from the group consisting oflovastatin, simvastatin, pravastatin, fluvastatin, artorvastatin,cerivastatin, pitavastatin, rosuvastatin and mixtures thereof.
 14. Thepharmaceutical composition of claim 13 wherein the salts of statindihydroxy acids include at least one of the cation salts of sodium,potassium, aluminum, calcium, lithium, magnesium, zinc, andtetramethylammonium and amine salts including at least one of ammonia,ethylenediamine, N-methylglucamine, lysine, arginine, orthinine,choline, N,N′ dibenzylethylenediamine, chloroprocaine, diethanolamine,procaine, N-benzylphenethylamine,1-p-chlorobenzyl-2-pyrrolidine-1′-methylbenzimidazole, diethylamine,piperazine, morpholine, 2,4,4-trimethyl-2-pentamine, andtris(hydroxymethyl)aminomethane.
 15. The pharmaceutical composition ofclaim 14 wherein the salts of statin dihydroxy acids further include atleast one ester derivatives including at least one of unsubstitutedalkyls having 1 to 4 carbon atoms and substituted alkyls having 1 to 4carbon atoms, wherein the substituted group is at least one ofphenyl-dimethylamino- and acetylamino-groups.
 16. The pharmaceutical ofclaim 15 wherein the alkyl group is one of methyl, ethyl, n-propyl,n-butyl, isopropyl, sec-butyl, and tert-butyl.
 17. The pharmaceuticalcomposition of claim 10 wherein the salts of fibric acid include atleast one of cation salts of sodium, potassium, aluminum, calcium,lithium, magnesium, zinc, and tetramethylammonium and amine saltsincluding at least one of ammonia, ethylenediamine, N-methylglucamine,lysine, arginine, orthinine, choline, N,N′ dibenzylethylenediamine,chloroprocaine, diethanolamine, procaine, N-benzylphenethylamine,1-p-chlorobenzyl-2-pyrrolidine-1′methylbenzimidazole, diethylamine,piperazine, morpholine, 2,4,4-trimethyl-2-pentamine, andtris(hydroxymethyl)aminomethane.
 18. The pharmaceutical composition ofclaim 17 wherein the salts of fibric acid further include at least oneester derivative including at least one of unsubstituted alkyls having 1to 4 carbon atoms and substituted alkyls having 1 to 4 carbon atoms,wherein the substituted group is at least one of phenyl-dimethylamino-and acetylamino-groups.
 19. The pharmaceutical composition of claim 17wherein the alkyl group is one of methyl, ethyl, n-propyl, n-butyl,isopropyl, sec-butyl, and tert-butyl.
 20. The pharmaceutical of claim 9wherein the bile acid sequestrant includes at least one ofcholestyramine, colestipol, and colesevelam.
 21. The pharmaceutical ofclaim 9 wherein the niacin compound is nicotinic acid.
 22. Thepharmaceutical composition of claim 1 further comprises at least one HIVprotease inhibitor.
 23. The pharmaceutical composition of claim 22wherein the HIV protease inhibitor includes at least one of indinavir,nelfinavir, ritinavir, and saquinavir.
 24. The pharmaceutical of claim 1wherein the HMG CoA reductase inhibitor and the additional therapeuticagent are formulated in an enteric coated dosage form wherein asubstantial release of the compound from the dosage form after oraladministration to a patient is delayed until passage of the dosage fromthrough the stomach.
 25. The pharmaceutical composition of claim 24wherein the dosage form is surrounded by an enteric coating.
 26. Thepharmaceutical composition of claim 24 wherein the composition isformulated in an enterically coated rapid-release pharmaceutical dosageform.
 27. The pharmaceutical composition of claim 24 wherein thecomposition is formulated in an enterically coated time controlledrelease pharmaceutical dosage form.
 28. The pharmaceutical compositionof claim 24 wherein the enteric coating is comprised of polyvinylacetate phthalate, titanium dioxide, talc, colloidal silicon dioxide,triethyl citrate, polyethylene glycol, sodium bicarbonate, purifiedstearic acid, and sodium alginate.
 29. A method of inhibiting HMG-CoAreductase and raising high density lipoprotein cholesterol levelscomprising administering to a patient an effective amount of an oralpharmaceutical composition containing a statin selected from the groupincluding dihydroxy-acid salts of at least one of lovastatin,simvastatin, pravastatin, fluvastatin, artorvastatin, cerivastatin,pitavastatin, rosuvastatin and at least one additional therapeuticagent.
 30. The method of claim 29 wherein the additional therapeuticagent includes at least one of peroxisome proliferator activatedreceptor agonists, cholesterol ester transfer protein inhibitors, longchain carboxylic acids and ether compounds.
 31. The method of claim 29wherein the additional therapeutic agent includes at least one of awater-soluble salt of the free acid form of a fibrate, bile acidsequestrants, and niacin.
 32. The method of claim 31 wherein thewater-soluble salt of the free acid form of fibrate is at least one ofclofibrate, gemfibrozil, fenofibrate, bezafibrate, and ciprofibrate. 33.The method of claim 31 wherein water-soluble salt of the free acid formof fibrate includes at least one of cation salts of sodium, potassium,aluminum, calcium, lithium, magnesium, zinc, and tetramethylammonium andamine salts including at least one of ammonia, ethylenediamine,N-methylglucamine, lysine, arginine, orthinine, choline, N,N′dibenzylethylenediamine, chloroprocaine, diethanolamine, procaine,N-benzylphenethylamine,1-p-chlorobenzyl-2-pyrrolidine-1′methylbenzimidazole, diethylamine,piperazine, morpholine, 2,4,4-trimethyl-2-pentamine, andtris(hydroxymethyl)aminomethane.
 34. The method of claim 33 wherein thewater-soluble salt of the free acid form of fibrate further include atleast one ester derivative including at least one of unsubstitutedalkyls having 1 to 4 carbon atoms and substituted alkyls having 1 to 4carbon atoms, wherein the substituted group is at least one ofphenyl-dimethylamino- and acetylamino-groups.
 35. The method of claim 31wherein the bile acid sequestrant includes at least one ofcholestyramine, colestipol, and colesevelam.
 36. An oral pharmaceuticalcomposition made by combining a therapeutically effective amount of acompound selected from a dihydroxy open acid statin present as apharmaceutically acceptable salt or ester thereof and at least oneadditional therapeutic agent with a pharmaceutically acceptable carrier.37. A method of inhibiting HMG-CoA reductase comprising administering toa patient in need of such treatment an effective inhibitory amount ofthe composition of claim
 1. 38. A method of inhibiting HMG-CoA reductasecomprising administering to a patient in need of such treatment aneffective inhibitory amount of the compound of claim
 3. 39. A method oftreating at least one of hypercholesterolemia and atheroscleroticdisease, comprising administering to a patient in need of such treatmenta therapeutically effective amount of the compound of claim
 3. 40. Amethod for preventing or reducing the risk of developing atheroscleroticdisease comprising the administration of a prophylactically effectiveamount of the compound of claim 1 to a person at risk of developingatherosclerotic disease.
 41. The method of claim 40 wherein theatherosclerotic disease is selected from cardiovascular disease,cerebrovascular disease and peripheral vessel disease.
 42. The method ofclaim 41 wherein the cardiovascular disease is coronary heart disease.43. The method of claim 31 wherein the salts of dihydroxy open acidinclude at least one of cation salts of sodium, potassium, aluminum,calcium, lithium, magnesium, zinc, and tetramethylammonium and aminesalts including at least one of ammonia, ethylenediamine,N-methylglucamine, lysine, arginine, orthinine, choline; N,N′dibenzylethylenediamine, chloroprocaine, diethanolamine, procaine,N-benzylphenethylamine,1-p-chlorobenzyl-2-pyrrolidine-1′methylbenzimidazole, diethylamine,piperazine, morpholine, 2,4,4-trimethyl-2-pentamine, andtris(hydroxymethyl)aminomethane.
 44. A method for addressing at leastone disease exhibiting HMG-CoA reductase activity, the disease includingat least one of Alzheimer's disease, cancer and transmissible spongiformencephalopathies, the method including the step of levels comprisingadministering to a patient an effective amount of an oral pharmaceuticalcomposition containing a statin selected from the group includingdihydroxy-acid salts of at least one of lovastatin, simvastatin,pravastatin, fluvastatin, artorvastatin, cerivastatin, pitavastatin,rosuvastatin and at least one additional therapeutic agent.
 45. Themethod of claim 44 wherein the additional therapeutic agent includes atleast one of peroxisome proliferator activated receptor agonists,cholesterol ester transfer protein inhibitors, long chain carboxylicacids and ether compounds.
 46. The method of claim 44 wherein theadditional therapeutic agent exhibits effect on at least on at least onelipid abnormality presenting in a patient.